A Clinical Manual of Mental Diseases.
Journal: JAMA (1918)

The position of insanity, both as regards the community and the profession of medicine, has always been somewhat pecuhar.Long unrecognized as deaUng with diseased states, it was looked upon as something apart from medicine, and up to quite recent times it was the subject of religious and superstitious interpretation.All ancient peoples-the Egyptians, the Hebrews, the early Greeks-looked upon the insane a,s persons possessed of evil spirits, as the victims of demoniac posses- sion, or, more rarely, as the inspired instruments of the Deity.These crude and fearsome explanations were singularly like those of the barbarous peoples of our own day.In the rise of the Greek, the Alexandrian, and the Roman civilizations, superstition gradually lost ground and various scientific explanations were adopted.The insane were looked upon as persons who were ill, and they were frequently treated by drugs, baths, exercise, and other hygienic measures.However, beginning with about the second or third centuries of the Christian era, a great retrogression took place.Theories of 2 17 MENTAL DISEASES demoniac possession, of sorcery, and witchcraft again held sway, and the insane were subjected to neglect, cruelty, and torture.This attitude of superstition continued throughout the Middle Ages, and, indeed, until long after the dawn of the Renaissance.It was not until the eighteenth century that any marked ad- vance was made.The insane were still confined in dungeons, badly fed, clothed in rags, and weighted down with chains.Various places for the custody and care of the insane were, however, gradually established; for instance, in Rome, in Bethlehem, England, in Ghent and Gheel in Belgium, and in the Hotel Dieu in Paris; but no real provision was made for their humane care until the latter part of the eighteenth century, when Pinel, in France, Tuke, in England, and Benjamin Rush, in America, made the first real advances.In 1793 PhilipPinel was appointed physician to the Bicetre, and substituted a system of non-restraint and humane treatment for blows and punishments.At the same time that Pinel was making these great strides in France, William Tuke, a member of the Society of Friends, who was not even a physician, began simi- lar reforms in England.He established a retreat or asylum at York, which was opened in 1796, and in which a rational care and humanity were likewise the guiding principles.Subsequently these methods, though slowly, were adopted elsewhere.Scientific conceptions as to the nature of insanity were likewise very slow in developing.The essentially sinful character of insanity, advocated by Stahl in the early eighteenth Century, still found its advocate in the person of Heinroth in the early nineteenth.Little by little, however, metaphysic and psy- chologic explanations began to take the place of religious theories.The latter were finally definitely abandoned, and physicians began to reason about insanity in a philosophic, though purely speculative way ; science had not yet made possible the framing of views based upon fact.Physicians were is ill, that his body is diseased, that he no longer has a mouth, that he has a snake in his stomach, that his viscera have been removed, or that he has some hopeless physical ailment.Such delusions may be spoken of as somatic or as hypochondriac.Very frequently spiritual and somatic delusions exist in the same patient, and often it is not possible to separate them, ideas of spiritual unworthiness and bodily disease being intermingled.We should remember, also, that depressive delusions may relate neither to the spiritual nor physical makeup of the patient, but may assume the form of delusions of persecution.Two terms which are frequently used in speaking of the insane require a moment's attention.They are neurasthenic and neu- ropathic.The word "neurasthenia" literally means without nervous strength, and a neurasthenic patient is one presenting a group of symptoms indicative of exhaustion and chronic fatigue.Neurasthenia deals essentially with functional con- ditions.The word "neuropathic," on the other hand, is applied to those fundamental deficiencies and aberrations of the nervous system which predispose it to disease, or which of themselves entail disease and degeneration.Neuropathy has its origin in basic morphologic and functional deviations and weaknesses, and, as might be supposed, it is largely hereditary and plays an im- portant role in mental disease.The changes present in neuro- pathic states, as a rule, embrace the organism as a whole.Some peculiarity of structure, which has its origin in aberrant and defective development, in the ductless glands, in vascular supply, or in some other unknown quality which favors degeneration of the nervous system, is transmitted from parent to child, and it is this tendency to degeneration which is termed neuropathic.Other terms used in the description of mental symptoms will be considered and defined as occasion arises.CHAPTER II CLASSIFICATIONPathology has as yet so little to offer that we must content ourselves with a purely clinical interpretation of insanity.A clinical interpretation is not only of practical value, but it is also interesting and scientific.The clinical interpretation of a disease means literally its bedside interpretation, and into such an interpretation there enters every fact at our disposal, near or remote-not only the symptoms presented by the patient, not only his family history and his personal history, not only his sex, his age, or epoch of fife, but all that we know of the changes in the tissues, and of the course, the duration, and the prognosis of the disease in similar cases.In attempting MENTAL DISEASES mental disorders.I will not here deal with the causes of delirium, confusion, or stupor.A sufficient hint is afforded us in the clinical history.We have at once suggested to our minds the action of the bacteria, of bacterial toxins, and of other poisons upon the cortex.It is probable that in delirium we have especially and essentially such an action, while in con- fusion and stupor we have the added factors of exhaustion and secondary changes in metabolism.The above considerations show that delirium, confusion, and stupor are closely related forms, and we construct of them the first group of our classification of mental diseases.As pointed out, they are more or less characterized by the presence of hallucinations, illusions, unsystematized delusions, incoherence and confusion.As our studies progress we will learn, in addi- tion, two important facts: first, that the emotional state, though it may be disturbed, plays only a secondary role; and secondly, that heredity is, in this group, of subsidiary importance.In these respects, delirium, confusion, and stupor differ radically from the next group of mental diseases to be considered; namely, melancholia, mania, and circular insanity.Here the emotional state dominates the entire clinical picture and outweighs all other symptoms.Secondly, the affection, whether it be mania or melancholia, pursues a wave-like course.Heredity also plays a most important role; it is a striking factor in"the clin- ical history of the great majority of cases.Further, as we study these affections, we will recognize that they are closely related to each other.In melancholia the patient passes through a phase of emotional depression ; in mania, through a phase of emotional exaltation, and in circular insanity, through both of these phases, one after the other.The symptom group of melanchoha-mania differs, of course, radically from that of delirium, confusion, and stupor.We have, for example, in the phase of mania, as we willIn the course of our studies we will next consider insanity from the point of view of internal medicine; this is practically of great importance.We will consider the relation which insanity bears to the various infectious diseases, to the intoxi- cations, to the disorders of metabolism, to the various diseases of the viscera, to the diseases of the nervous system, and, lastly, to pregnancy, the puerperium, and lactation.We will further study the subject as related to the various epochs of life, namely, to infancy, puberty, early adult age, mature adult age, middle age, and old age.Finally, we will consider briefly certain mental diseases not usually included under insanity, and also insanity by contagion.CHAPTER III GROUP I-DELIRIUM, CONFUSION, STUPOR Delirium, the first member of this interesting group, occurs as a very common epiphenomenon of fevers, infection, intoxi- cation and exhaustion.It is, therefore, a condition which frequently falls under the observation of the practitioner.Once comprehended, it explains much that is met with in the allied states of confusion and stupor.We have already enu- merated its principal features in the preceding chapter on Classification (see p. 27).These were illusions, hallucinations, and unsystematized delusions.To these must be added ex- aggerated cerebral activity and physical restlessness.Further, delirium is always of short or relatively short duration.If asked to define "delirium," we may say that it is an active men- tal disturbance, characterized by the presence of illusions, hal- lucinations, fragmentary, fleeting, unsystematized delusions, in- coherence, cerebral excitement, physical restlessness, and by a relatively short course.All deliria are essentially alike, though they differ somewhat in their details.They naturally separate themselves into two groups, the febrile and the afebrile forms.The febrile deliria are those which accompany the various acute infections, the exanthemata, and the various acute visceral diseases, such as pneumonia.The afebrile deliria are those which are met with as sequelae of various infectious diseases, as a result of various intoxications, and after trauma or shock.The afebrile deliria may have their onset during the period of convalescence-the appearance, which rapidly assumes a great intensity.It is furious in character, the patient raves, shouts, sings; his fea- tures express in rapid sequence fright, anger, terror, anguish, ecstacy.He struggles, tries to escape or to hide, he weeps, shrieks, or may, for brief intervals, laugh or smile.From his lips issue fragments of sentences, broken phrases, half-articulated words.He is entirely obtunded to his surroundings, he cannot, as in deliria of less violent form, be brought in any degree to a realization of his surroundings.Indeed, even illusions are not formed, and the patient appears to be entirely at the mercy of his hallucinations.The latter are, in the main, painful and terrifying, as are the disordered ideas to which they give rise, and, in this respect, the symptoms resemble those of ordinary febrile delirium, save that they are magnified and ac- centuated.Paroxysms of terror associated with staring eyes, shrieks, and mad struggling can only depend upon frightful hallucinations; and the phrases the patient utters, often understood with difficulty, are of murder, fire, blood, and tortures.The ideas reveal no sequence other than that of a torrent of disordered and fragmentary delusions, painful in the extreme.Certain ideas may recur, or certain groups of ideas, such as of fire and of being burnt alive, of torture or poisoning, may predominate, but no coherence or systematization obtains.The patient's restlessness is extreme; in the intervals of his struggles he is in a continual state of agitation, and constantly moving unless restrained.He is picking or pulling with his hands, tearing at his clothes, grasping at the air, pushing away or warding off imaginary dangers.He may spring from his bed, throw himself against the walls, furniture, or attendants.As might be expected, food and drink can rarely be administered; the food may be retained in the mouth for a mo- ment, only to be suddenly ejected; at times a mouthful may MENTAL DISEASES tion, especially about the vessels; its nuclei may be increased and its network more pronounced.The changes observed seem to indicate the action of some poison, most probably the toxin of some infection.However, the evidence at hand is as yet extremely meager and unsatisfactory.Bianchi and Piccinino have described a bacillus found in the blood of delirium grave which is not foimd in other deliria, and which they believe to be specific.However, other observers have noted the presence in the blood of staphylococci, streptococci, and diplococci, to which obviously no specificity could be ascribed.Again, others still, such as Cabitto, have failed in undoubted delirium grave to find any microbic infection whatever.It is impossible, of course, in the present state of our knowledge to form a definite opinion, or even to determine whether delirium grave is a specific infectious disease.Indeed, it is not impossible that it is a syndrome which may be the outcome of diverse infective agents.However this may be, it must be admitted that delirium grave is a clinical entity; that it pre- sents special features as regards its evolution, its symptoms, its course, and its termination, and as such it demands special study and consideration.Diagnosis.-Theabsence of the physical signs of the exanthemata and of the visceral diseases of infectious origin, together with the presence of a delirium of rapid evolution and great intensity, accompanied by high temperature, should suggest at once the existence of specific febrile delirium.In other affections, the history of a period of invasion and the signs present at the time of the evolution of the delirium leave, as a rule, no doubt of the existence of one of the eruptive fevers, erysipelas, pneumonia, meningitis, articular rheumatism, or of pelvic, abdominal, or other local lesions.The clinical picture is always very different; thus, in a meningitis, the delirium is MENTAL DISEASES ture, and that this is either accompanied or followed by an attack of dehrium.Again, it may be that the infectious dis-ease from which the patient suffers has pursued and completed a normal course, and that the patient has entered the stage of convalescence, when the latter is interrrupted by an attack of delirium.As might be expected, afebrile delirium may occur in widely separate affections.Thus, it may occur during or as a sequel in the various exanthemata, in typhoid fever, in pneumonia, in influenza, and in various other conditions in which sudden exhaustion may supervene; for example, in labor, in the puerperium, sudden hemorrhage, surgical shock, great emotional shock, and fright.There is present in some cases in which such a delirium occurs an undoubted predisposition to mental disturbance-a hereditary neuropathic make-up-but this is probably true of less than half the cases.Symptoms and Course.-Theonset is usually sudden, though at times prodromal symptoms may be noted.Thus, for a day or two insomnia and an ominous restlessness may make their appearance.Consciousness becomes much obscured;the patient loses the proper appreciation of his surroundings;he becomes illusional, everything seems strange and changed; soon, also, he becomes hallucinatory to an extreme degree.The chairs and other objects in the room are mistaken for strange shapes, persons, or animals.The individuals about his bed are no longer properly recognized.The pictures upon the walls, the curtains upon the windows, the rugs upon the floor, all become